The work was carried out on the basis of MC «I. I. Mechnikov Dnipropetrovsk Regional Clinical Hospital» and Dnipro State Medical University during 2018 - 2022, devoted to optimizing the choice of the method of pancreatodigestive anastomoses formation.
Objective: to improve the results of surgery treatment of the patients with formed pancreatodigestive anastomoses due to the improvement of methods of their implementation, timely diagnosis of early postoperative complications, optimization of the choice of anastomosis taking into account risk factors.
The paper analyzes the results of examination and treatment of 108 patients, who underwent surgical treatment in the scope of the standard PD. There were 57 (52,8 %) women and 51 (47,2 %) men aged from 24 to 74 years old among them. The average age of patients was 56,2 ± 9,7 years old. Depending on the formed pancreatodigestive anastomosis (PDA) the patients were divided into the groups: pancreatojejunostomy (PEA) – 88 (81,5 %), pancreatogastroanastomosis (PGA) – 20 (18,5 %). In the PEA group there were divided the subgroups: Wirsung-jejunostomy (n=28), telescope-type PJ «end-to-end» (n=26) and PEA formed under the original method (n=34).
The selected groups of patients were compared by age, sex, localization of the pathological process, histological structure of the formation, presence of comorbidities (p ˃ 0.05).
We analyzed the complications occurred in patients in the early and late postoperative period. The total number of patients with various early postoperative complications was 47 (43.5 ± 4.8 %), with 2 different complications per patient on an average. Pancreatic fistulas and bleeding of various localizations – 28 (59.6 ± 6.2 %) dominated in the structure of early postoperative complications. There were no statistically significant differences in the number of late postoperative complications among the groups. In the long-term period after PD the life quality indicators and pancreatic function were studied depending on the type of anastomosis. The results of patient with PGA were worth.
The risk factors for early postoperative complications were identified including: presence of cardiovascular system diseases (OR = 2.12; 95 % CI 1.06 – 4.66; р < 0.05), volume and severity of blood loss during surgery (OR = 3.43; 95 % CI 1.50 – 7.84; р < 0.01); pancreas parenchyma density in the area of anastomosis formation (OR = 3.13; 95 % CI 1.42 – 6.91; р < 0,01); diameter of the Wirsung duct (OR = 2.8; 95 % CI 1.12 – 7.03; р < 0.05). Appearance of pancreatic fistulas in the early postoperative period was an unfavorable factor from the point of view of the other early postoperative complications development (OR=84.2; 95% CI 4.91-1443.4; p<0.001). Therefore, factors for the pancreatic fistulas forming were identified separately. The body mass index of patients (OR = 3.13; 95% CI 1.11 - 8.80; p <0.05) and number of bleeding vessels on pancreas section (OR = 5.78; 95 % CI 1.77 - 18.87; p <0.01) were added to the predetermined indicators.
There was used the comparative analysis of the methods for preoperative assessment of the pancreas condition with the palpation data during surgery and the results of histological examination. It was found that palpation during surgery was the best method to predict the pancreatic fibrosis (correlation of fibrous tissue area in both percentage and μm2 was significant (rs = - 0.76 and rs = 0.64; p ≤ 0.05), and among the preoperative methods the best results were shown by shear wave elastography (rs= - 0.55 and rs = 0.42; р ≤ 0.05). Cutoff points were established for pancreatic density (at Еmed > 5.762 kPa, Vmed> 1.382 m/s the gland can be considered dense; at Еmed <5.762 kPa, Vmed <1.382 m/s – soft).
The risk of early postoperative complications was calculated using the logit regression equation. It can be calculated both before and immediately after surgery. In so doing, this forecast has good characteristics according to the results of ROC analysis: area under the curve AUC = 0.7, 95% CI (0.602 - 0.786), sensitivity – 81.7%, specificity – 50.0%, p <0.001. For the model immediately after surgery these characteristics are even better: the area under the curve AUC = 0.747, 95% CI (0.655-0.826), sensitivity – 88.5%, specificity – 53.2%, p <0.001.
Based on the logit regression equation and previously obtained data, the algorithm for differentiated approach to choice of pancreatodigestive anastomosis method was developed. With a low risk of postoperative complications (у ˂ 0.5) determined before surgery, we believe that any variant of pancreatodigestive anastomoses can be formed: Wirsung-jejunostomy, telescopic PEA, original PEA, PGA. With a high risk of complications, according to our statistics, it is advisable to choose between the original PEA and PGA, because the number of early postoperative complications between them was similar (p ˃ 0.05).
